Smallpox: What the Dermatologist Should Know

Phyllis I. Spuls, MD; Jan D. Bos, MD, PhD; Donald Rudikoff, MD


Skinmed. 2004;3(4) 

In This Article

Abstract and Introduction

Despite the eradication of naturally occurring smallpox in 1977, stores of the virus have been maintained in laboratories in the United States and Russia. It is feared that certain rogue states and terrorist organizations may have illicitly acquired the virus with the intent of unleashing it as an agent of bioterrorism. The United States and other nations have begun vaccinating individuals in the military and health care workers who might become exposed. Primary care providers and dermatologists will be called upon to evaluate potential index cases and vaccination reactions. In this report, the authors review the essential clinical aspects of smallpox and potential reactions to smallpox vaccination. Special attention is given to eczema vaccinatum, which can occur in vaccinees and their family contacts with active or quiescent atopic dermatitis or a personal history of eczema.

Although the last reported case of naturally acquired smallpox occurred just over 25 years ago,[1] public health officials fear the virus could be unleashed as a weapon of bioterrorism in the aftermath of the attacks of September 11, 2001.[2,3,4] Dermatologists should familiarize themselves with aspects of this disease for a number of reasons: 1) the primary manifestations of smallpox are mucocutaneous, so dermatologists will likely be called upon to diagnose index cases; 2) many side effects of vaccination involve the skin; and 3) patients with active eczema or a history of eczema are at risk for serious adverse effects from vaccination. Dermatologists will be asked by their patients whether they or their children can safely be vaccinated.

This review provides a brief history of smallpox, a description of the common clinical features and diagnostic approach, and reviews vaccination and its complications, particularly eczema vaccinatum.[5] The immunology of this complication and its treatment are summarized.


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